Kuito provincial hospital was founded in 1936. MSF has been present in the provincial capital since 1989 and has provided substantial support to the 435-bed Kuito hospital since February 1990. At several points during the brutal war for Kuito, MSF was the sole provider of drugs, materials and staff for what was the only functional hospital in the province. Since the handover of the hospital to the Angolan Ministry of Health (MINSA) in February 2003, MINSA has performed some renovation of the hospital structure, but has faltered with the provision of qualified staff and essential drugs. Despite the authorities' first efforts to rebuild the health care system, over 40 years of civil war cannot easily be undone.

MSF handover guidelines generated from evaluation learning

This document, based on MSF OCB HIV/TB programming experience from 2006-2014, provides a practical and user-friendly resource for people to consult about issues related to project handovers. The toolkit moves through all the phases of the project cycle to demonstrate how the handover process can and should be incorporated at every stage. It is hoped that the templates, real field examples and reports referenced here will be useful for those in the field and allow field teams to be able to say that they, with all MSF’s knowledge and experience, gave the handover their best shot. Acknowledging that many resources already exist, this toolkit seeks to avoid re-inventing the wheel and merely to build upon what exists by guiding the reader to the original material as needed.

This document, developed by MSF UK, was the precursor to the above toolkit and shares a similar objective. While the toolkit focuses on the whole project cycle, this report focuses on the practical side of implementing a handover once MSF has taken the decision to withdraw from a particular project. The key steps – negotiating a handover strategy, establishing a handover dashboard, creating a handover steering committee – are explained in depth.

Like the above documents, this guideline is intended to support teams in the planning and implementation of the handover of a project. Unlike the above, it is quite short and is specifically based on the evaluation results of the Mundari hospital in Kajo Keji County, South Sudan (see below). The document is intended to serve as a guide without intending to be complete – it needs to be adapted to every context. That being said, it outlines a list of primary questions to clarify before a handover, general recommendations, steps for a handover, and a preliminary timeline for handover planning in the form of a Gantt chart.

MSF Evaluations

MSF OCP has been working in HIV care in Homa Bay County since 1996. The handover process was initiated in 2013 and scheduled to be completed in December 2015. The objective of this evaluation was to take stock of the 2.5 years of handover, to provide feedback on its effectiveness, appropriateness, impact, connectedness and continuity of care by highlighting operational strengths and weaknesses and areas of improvement and to provide recommendations.

The Gogrial project (South Sudan) began in 2009 with an objective to preposition medical and surgical capacity close to possible conflict areas expected around the referendum in 2011. This did not occur, yet the project continued. The handover process was initiated in 2015, but experienced a crisis in mid-2015 which led to MSF extending its presence through to 2016 to ensure proper handover. This review aimed to capture learnings from this difficult exit process in South Sudan and provides an overview of the root causes identified, both internal and external.

After 10 years in Zinder, Niger, the MSF mission began preparing to handover the project to the national authorities. MSF still needed to ‘run the last mile’ in order to close its cycle in Zinder and to leave its nutritional involvement completely to the national authorities. The current evaluation was a follow-up on the initial capitalisation report done in 2014 (see below) and was initiated to assess the future of this handover, and whether it would be feasible or not to completely handover nutritional activities to the HNZ (Zinder National Hospital).

OCB initiated the Kibera project in 1997 to reduce mortality and morbidity among people living with HIV/AIDS in Nairobi. The handover process was officially conceptualized in early 2014 (following the 2013 evaluation – see below) to be finalized by mid-2017. This evaluation took place mid-way through the handover process in 2015. The objectives of the evaluation were to (i) establish the extent to which project objectives have been achieved in one year of the handover process (2014-2015) (ii) determine the appropriateness and effectiveness of the handover process (iii) identify the challenges faced and lessons learned during the last year of the handover process (iv) make recommendations on adjustments and strategic adaptations to be considered for the handover process to be completed efficiently and within the planned time.

The Roma and Semongkong project began in 2011 with the aim to reduce maternal and infant morbidity and mortality in a hyper-epidemic HIV/TB setting. This end of project evaluation was commissioned to assess the impact of the five-year programme and identify lessons learned to support the design and planning of potential future projects in Lesotho. Specific objectives of the evaluation were to 1) review the project impact on policy change; 2) analyse the appropriateness of the operational strategy and the operational model of care; 3) analyse the impact on health results; 4) review the handover process

Since 2012 OCA has been implementing a new approach to HIV/TB programming in Gokwe North district of Zimbabwe. In September 2014, towards the end of its handover, an evaluation was commissioned with the objective to find out whether the approach could be recommended for use again by MSF-OCA. In terms of handovers, this evaluation contains an analysis of how the lessons learned from a previous handover evaluation in Gweru influenced the setup of the Gokwe North intervention, as well as some handover-related recommendations.

MSF has been supporting the provision of HIV prevention, treatment and care in Maputo, Mozambique since 2001, and the handover process began in 2011. This evaluation aims to assess the appropriateness and effectiveness of the handover strategy and likely outcome in continuity of care, in order to provide a comprehensive overview of the implementation phases of the handover as well as to make clear recommendations towards future improvements and replicability of the handover ‘tool’ itself.

The precursor to the 2016 review, this evaluation assessed the earlier phases of the handover process of the nutritional programme in Zinder. The objective was to assess best practices, challenges and lessons learnt of the handover/integration process of the Zinder CRENI to the hospital, with the main purpose to improve handover processes in such contexts as well as decision-making in future projects.

The HIV/TB project in Guinea ran from 2011-2013. The purpose of the evaluation was to collect and analyse information on the implementation of the project, to document lessons learned, bottlenecks and risks that could jeopardize the sustainability of project achievements. In terms of handovers, the evaluation expressed serious concern over the ability of local partners to effectively continue the fight against HIV and TB after MSF’s departure, and made a series of recommendations related to handover processes.

MSF Belgium was active in Thyolo District from 1998, supporting the Ministry of Health (MoH) in the provision of STI and HIV-TB care and treatment. This evaluation takes stock of the two and a half year handover process that started in June 2011. The evaluation highlights both the operational strengths and weaknesses and identifies areas for improvement. The work aims to inform the replicability of the handover tools and approach.

The Kibera project began in 1997 to reduce mortality and morbidity among people living with HIV/AIDS in Nairobi. The forerunner to the 2015 evaluation (see above), this evaluation was undertaken to assess the ongoing model of care and determine if the handover strategy was on track towards reaching the defined objectives with regards to continuation of care.

In 2001, MSF-OCB began supporting the MOH in Mozambique in providing HIV care and treatment and PMTCT. The purpose of this evaluation was to gain a better understanding of how MSF support in Mavalane was perceived by stakeholders in the area and to gain a better understanding and receive recommendations from other stakeholders on the handover strategy proposed by MSF. In this case, most stakeholders, including other international HIV partners, felt that the handover of first line support was premature.

MSF-OCG was treating Kala Azar in Kacheliba, Kenya from 2006. In 2010, the Kenyan government created the Department for Neglected Diseases, with whom MSF was invited to form a partnership. MSF decided to collaborate, extending the project duration in Kacheliba until the end of 2012, to allow for capitalization on the Kacheliba experience. This evaluation was commissioned to look retrospectively at the appropriateness and effectiveness of the partnership between MSF and the Department for Neglected Diseases and prospectively at the exit strategy for the Kacheliba project.

The Bon Marché hospital situated in Bunia, DRC was built by MSF in 2003 at the height of inter-ethnic clashes in the area, to provide free and quality health care. As the situation became more stable and the government took the initiative to strengthen the capacity of health facilities a disengagement process was instigated in 2007. The purpose of this evaluation was to assess the appropriateness and effectiveness of the handover strategy to inform and improve the hand-over of MSF’s activities in Bunia (in 2010 and beyond) and to document lessons from the disengagement process to enable other MSF projects to learn from it.

In January 2006, MSF and the Ministry of Health and Social Welfare of Lesotho launched a joint pilot programme to provide decentralised HIV/AIDS care and treatment at the primary health care level. The Lesotho project is unique within the MSF OCB portfolio in that it was given the specific challenge to envision an exit strategy from the beginning and to utilise relatively limited MSF resources and input, instead emphasising the building of local capacity with a view to ensuring continuity of services over the long-term, independent of MSF. The main goal of the evaluation was to determine whether a handover tool that was implemented during the initial phase of the handover can help the team and the project to ensure some sustainability post MSF departure and if it can / should be replicated in other projects.

Following up on the evaluation below, in 2008 reproductive and maternity services, as well as PMTCT and SGBV services were transferred to three nearby locations. This evaluation aimed to: evaluate the effectiveness of the withdrawal and handover process in the light of the context at the end of 2009, the extent of collaboration with the MoH and other participants, the effectiveness of capacity building, the effectiveness of the handover in terms of consequences for patients, and the effectiveness of the operational strategic decisions for withdrawal.

MSF has been present in the Nchelenge region since 1998. The project in Nchelenge District was started in April 2001 because of lack of access to HIV/AIDS care in an area with an HIV prevalence estimated at 16.5%. The objective was to achieve a high coverage of treatment and care, and at the same time provide a model for decentralised programs to bring HIV/AIDS treatment and care to all people in Zambia and for MSF Holland/OCA more widely. The aim of the evaluation was to document the HIV/AIDS care in place for people living with HIV/AIDS (PLWHA) in Nchelenge District, Zambia, 2 years after the handover of the program from MSF-OCA management, to the Ministry of Health, Zambia (MoH) and the Zambian Care, Prevention and Treatment Program//Family Health International (ZPCT/FHI).

The handover of MSF-F Phnom Penh HIV project is a complex process. This HIV cohort is the biggest of MSF OCP to be handed over so far and the hand over is almost directly done to the national health authorities, NGO partners having been identified only for minor parts of the project. In the first part of the report, a narrative description and an evaluation of the main technical aspects of the handover process are presented. In the second part, a capitalization of experience is reported concerning technical aspects of specific interest and good practices identified within this project (decision making, interaction with partners, etc.).

MSF has been running HIV/AIDS treatment programmes since 2001 and began to hand over HIV projects in 2005. This Transversal Handover Evaluation was proposed by OCG to review recent and ongoing HIV/AIDS project handover processes, to analyse elements of continuity and appropriateness of handover strategies, and to make recommendations for policy and practice.

In September 2009, MSF carried out an assessment of two of its former projects in Karuzi (OCB) and Kinyinya (OCA), Burundi. These two projects were handed over to MOH in 2007 with significant investment from MSF in the handover processes. Following reports of the breakdown of healthcare after MSF’s departure and criticism on the way the handover of these two projects was managed, MSF wanted to assess the current situation in the two sites and document which, if any, handover strategies were successful and led to the continuation of MSF activities. The objective of the assessment was to inform and improve future handover strategies.

After an initial period of three years in Lesotho, MSF has decided to extend its presence in the country for two more years and to launch a second phase of the project primarily focused on intensifying the transfer of responsibility for the programme to local health authorities and partners. The evaluation assessed whether the 7 operational objectives for the handover were being met in Maseru district, and to make recommendations for the future of the handover.

The post-war years in Liberia were marked by sporadic outbursts of violence and a devastated health care system. The Benson hospital was opened to offer free maternity and pediatric hospital care for some of the most impoverished of Monrovia, where maternal and child mortality were among the worst in the world. The primary purpose of this evaluation was to help the field and HQ staff of MSF make informed decisions on the future of the Benson Hospital project, particularly the focus of future activities and a potential time frame for the handover of the services currently provided by MSF to other actors in Liberia. As such this evaluation took place before the handover.

The formation of the HIV/AIDS Adherence Counsellors Organisation (HAACO) was initiated by MSF who had been operating a HIV/AIDS project since 1999 in Khayalitsha in the Western Cape and since 2003 in rural Lusikisiki in the Eastern Cape province. Most of the services provided by the MSF project were handed over to the DoH. However the adherence element was not. The DoH had neither the financial nor the structural capacity to take on the Adherence programme. Hence the formation of HAACO. This evaluation was conducted to establish whether HAACO interventions were working, at what cost, to consider ways in which to strengthen HAACO, and review strategic options for the future of HAACO.

MSF began working on HIV/AIDS care in Humera in 2001. As funding for HIV/AIDS projects rocketed, there was less need for MSF to continue its project. This report documents the timeline and lessons learned of the handover.

MSF closed all operations in Lusikisiki at the end of October 2006. That date marked the end of four years of operations setting up a model of comprehensive and decentralized HIV care in one of the poorest and most underserved rural areas in South Africa with a high prevalence of infection. The model implemented has been widely used in South Africa to influence relevant policies. This report looks at the chain of events following the handover and changes in the model of care.

MSF had been working in Honduras and Guatemala in HIV prevention and care for several years before ART projects were started in 2001. In 2005 the projects were handed over to the National AIDS Programme, though MSF-CH kept some staff in both countries to monitor progress. This evaluation was planned a year and a half after handing over the project, to document the perception of people regarding lessons learnt; whether the project was handed over properly; and the quality of care for people living HIV.

Following the handover of AIDS treatment programs to the authorities of Guatemala, MSF conducted a study to assess various aspects of the continuity of HIV/AIDS care. This review was conducted 18 months after MSF left the Roosevelt hospital, and examined both the clinical data and opinions of staff and patients.

In 1997, MSF-CH took over and rehabilitated Mundari hospital with the general objective to provide appropriate medical services to the county population and to continue to support the hospital as a referral centre. The hospital provided IPD- (medical, emergency, surgical and paediatric) and OPD services as well as treatment for TB, sleeping sickness and HIV/AIDS. This evaluation was conducted to assess the appropriateness and effectiveness of the hospital programme, of HIV integration, and the handover process.

The political context toward HIV and AIDS in South Africa is particularly difficult with a government denying the seriousness of the epidemic, with a minister of health undermining confidence in HIV program, not supporting policy changes nor fully budgeting for HIV program, promoting beetroots, lemon and olive oil to treat AIDS. This paper examines the organisation of the project and the organisation and results of the handover.